Treating Gay Men with Prostate Cancer
A reference guide for Physicians treating gay male patients diagnosed with prostate cancer.
It is estimated that 1 in 9 Canadian men will develop prostate cancer during their lifetime. Gay and bisexual men diagnosed with prostate cancer have unique experiences and needs compared to their heterosexual, cisgender counterparts. It’s important that the patient’s circle of care discusses the patient’s sexual practices and the sexual side effects of treatment. Discussing sexual practices ensures that informed treatment decisions are made, and side effects are managed appropriately.
The diagnosis of prostate cancer and its treatment can cause side effects that negatively affect a patients sexual functioning and satisfaction for both insertive (top) and receptive (bottom) partners. This will of course vary based on the stage at diagnosis and the treatment offered. Two important potential side effects include erectile dysfunction and bowel dysfunction.
Some treatment modalities for prostate cancer can result in erectile dysfunction. This will have an impact on both the patient’s sexual pleasure and potentially his self-esteem. It may also impact sexual position during intercourse. In a recent study of gay and bisexual men treated for prostate cancer, only 8% of participants reported being the insertive partner (top) during intercourse after treatment, compared to 42% before treatment. (3) It is important that patients are aware of these potential side effects and how they may impact their sexual activity and relationships with sexual partners.
Since the prostate is sensitive to touch, removal or destruction of prostate tissue can reduce sexual pleasure during receptive anal intercourse. In addition, both external beam radiation and brachytherapy can lead to radiation proctitis causing urgency, cramps, diarrhea and fecal incontinence. Bowel problems are reported by about 16% of patients in the first 2 months following treatment but can persist in up to 11% for 2 years or more (4). Men who enjoy receptive anal intercourse will need to be aware of these potential side effects and may need help managing their impact on sexual function and relationships.
The Canadian Cancer Society highlights the following potential affects following treatment of prostate cancer:
Erectile dysfunction – a relatively common side effect. This can be permanent or recover within 2 years. Consider management with PDE5 inhibitors, penile pumps or penile implants.
Dry orgasms – the patient can achieve orgasm but there’s no ejaculate. There is no treatment. Discuss this with patients and set realistic expectations. Patients should be encouraged to have open communication with their partners.
Infertility – If the patient wishes to have children, consider banking sperm before treatment.
Urinary incontinence – most commonly stress or urge incontinence. Manage with decreased fluids, Kegal Exercises, medications, and lastly surgery.
Decreased sex drive – do not use testosterone therapy as it encourages cancer growth. Connect the patient with a counsellor or sex therapist.
Low self-esteem – Reduced sexual functioning is one of the most prevalent and distressing side effects of treatment. Encourage the patient to discuss how they are feeling and provide a referral to a counsellor or sex therapist. (2)
In the absence of data, the following guidelines are based on the consensus opinion of 26 clinicians from The British Royal College of Radiologists, The British Association of Urological Surgeons, the British Uro-oncology Group, Prostate Cancer UK, and the Gay and Lesbian Association of Doctors and Dentists (2).
PSA Blood test – Instruct patients not to engage in receptive anal intercourse (bottom) for 1 week before this blood test. Recent receptive anal intercourse may cause falsely high results.
Trans-rectal biopsy (TRUS) – Patients should abstain from receptive anal intercourse for 2 weeks after this procedure. This allows time for healing and will reduce the risk of bleeding, pain and infection.
Trans-perineal biopsy – Patients should abstain from receptive anal intercourse for 1 week after the procedure. This will allow bruising to settle, and reduce the risk of painful intercourse.
Radical prostatectomy – Patients should abstain from receptive anal intercourse for 6 weeks after surgery. This allows time for healing and will reduce the risk of bleeding, pain, and urinary incontinence.
External beam radiotherapy – Patients should abstain from receptive anal intercourse for 2 months after therapy. Radiation proctitis is usually most severe in the first 2 months following therapy. Receptive anal intercourse may increase discomfort and bleeding (1).
Permanent seed brachytherapy – Patients should abstain from receptive anal intercourse for 6 months following therapy. This is to decrease radiation exposure to the partner during intercourse (5).
The experience of a diagnosis of and treatment for prostate cancer differs between men and in several ways for gay men. Impacts will include physical, sexual, psychological and social function. Be mindful and informed of the unique challenges gay patients may face when dealing with prostate cancer and be prepared to discuss these challenges with your patients.
For more information on the impact of Prostate Cancer for gay men, visit the Canadian Cancer Society at A guide for gay and bisexual men.
3) B.R.S. Rosser, N. Kohli, E.J. Polter, et al.
The sexual functioning of gay and bisexual men following prostate cancer treatment: results from the Restore Study Arch Sex Behav (2019)
4) Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, Lin X, Greenfield TK, Litwin MS, Saigal CS, Mahadevan A, Klein E, Kibel A, Pisters LL, Kuban D, Kaplan I, Wood D, Ciezki J, Shah N, Wei JT. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358(12):1250.